What is the recommended treatment plan for managing ulcerative colitis?

Management of Ulcerative Colitis: A Step-by-Step Treatment Plan

The recommended treatment plan for ulcerative colitis should follow a stepwise approach based on disease severity, extent, and response to therapy, starting with 5-aminosalicylates for mild-to-moderate disease and escalating to corticosteroids, immunomodulators, or biologics for refractory cases. 1

Initial Assessment and Classification

• Disease extent: Classify as proctitis, left-sided colitis, or extensive/pancolitis
• Disease severity: Mild, moderate, or severe based on:
  • Stool frequency and consistency
  • Presence of blood in stool
  • Urgency/tenesmus
  • Systemic symptoms (fever, tachycardia, anemia)
  • Laboratory markers (CRP, ESR, fecal calprotectin)

Treatment Algorithm by Disease Severity

Mild-to-Moderate Disease

1. First-line therapy:

   • Extensive disease: Standard-dose oral mesalamine (2-3 g/day) or diazo-bonded 5-ASA 1
   • Left-sided disease or proctosigmoiditis: Combine oral mesalamine with rectal mesalamine (enemas or suppositories) 1
   • Proctitis: Mesalamine suppositories are strongly recommended 1
   • Administration: Once-daily dosing is as effective as divided doses 1

2. Suboptimal response to initial therapy:

   • Increase mesalamine to high-dose (>3 g/day) plus rectal mesalamine 1
   • Monitor for 2-4 weeks for response

3. Failure of optimized 5-ASA therapy:

   • Add oral prednisone 40 mg daily with 6-8 week taper 1
   • Alternative for those wishing to avoid systemic steroids: budesonide MMX 1

Moderate-to-Severe Disease

1. Initial treatment:

   • Oral prednisone 40 mg daily with 6-8 week taper 1
   • Monitor for response within 7-14 days

2. Steroid-dependent or refractory disease:

   • Escalate to thiopurines (azathioprine/6-mercaptopurine) 1
   • OR initiate biologic therapy:
     • Anti-TNF therapy (e.g., infliximab 5 mg/kg at 0,2, and 6 weeks, then every 8 weeks) 1, 2
     • Vedolizumab 1
     • Tofacitinib 1

Acute Severe Ulcerative Colitis (Hospitalization Required)

1. Immediate interventions:

   • IV methylprednisolone 60 mg/day or hydrocortisone 100 mg four times daily 3
   • IV fluid and electrolyte replacement
   • VTE prophylaxis (critical - do not overlook) 3
   • Stool testing for C. difficile and other pathogens 3

2. Non-response to IV steroids after 3-5 days:

   • Rescue therapy with infliximab or cyclosporine 4
   • Surgical consultation for potential colectomy if medical therapy fails

Maintenance Therapy

• After induction of remission:
  • Continue 5-ASA at effective dose (typically 2-2.4 g/day) for mild disease 1, 5
  • Higher dose (2.4 g/day) better prevents and delays relapses compared to lower dose (1.2 g/day) 5
  • For patients requiring steroids for induction: add immunomodulator or biologic therapy 1

Monitoring and Follow-up

• Regular assessment of symptoms and inflammatory markers (CRP, fecal calprotectin)
• Colonoscopy after 8 years from diagnosis for dysplasia surveillance 6
• Monitor renal function periodically in patients on 5-ASA therapy 1
• For patients on immunomodulators: complete blood count within 4 weeks of starting therapy and every 6-12 weeks thereafter 3

Special Considerations

• Pregnancy: Most IBD medications are safe during pregnancy; active disease poses greater risk than treatment 3
• Cancer risk: UC increases colorectal cancer risk (4.5% after 20 years of disease) 6
• Quality of life impact: UC reduces life expectancy by approximately 5 years compared to the general population 6
• Avoid common pitfalls:
  • Inadequate initial dosing of 5-ASA
  • Failure to combine oral and rectal therapy for left-sided disease
  • Delayed escalation of therapy in non-responders
  • Overlooking VTE prophylaxis in hospitalized patients
  • Prolonged steroid use without steroid-sparing strategies

By following this structured approach based on disease severity and response to therapy, most patients with ulcerative colitis can achieve clinical remission, mucosal healing, and improved quality of life while minimizing complications and the need for colectomy.